A nurse is caring for a client who is pregnant in a provider’s office.
Relevant vital signs to help answer the questions are as follows: Medical History: 0830 Gravida 3 Para 2, 32 weeks of gestation, Allergies: Penicillin, Height: 163 cm, Weight: 78 kg, BMI: 30.6, 6 lb weight gain over the last 2 weeks.
The client reports “I have had a headache for 5 days, blurred vision, and dizziness. Tylenol does not relieve it.” The client reports swelling of their feet and fingers.
2+ pitting edema of the lower extremities noted bilaterally. Swelling of the fingers and hands noted.
Deep tendon reflexes 3+, absent clonus.
Fetal heart tones (FHT) 1. Which of the following findings should the nurse report to the provider? Select all that apply.
Visual disturbances.
Fetal heart rate.
Blood pressure.
Deep tendon reflexes.
Correct Answer : A,C,D
Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.
Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.
Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.
Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A blood pressure of 100/60 is within the normal range and does not pose a contraindication to oral contraceptives. While hypertension (high blood pressure) can be a contraindication, a blood pressure of 100/60 is not considered hypertensive.
However, it's essential to monitor blood pressure regularly in individuals using oral contraceptives, as some may experience a slight increase in blood pressure.
Choice B rationale:
Age is a significant factor when considering oral contraceptive use.
Adolescents under 16 years of age are generally not recommended to use oral contraceptives due to several concerns: Their reproductive systems are still developing, and hormonal contraceptives could potentially disrupt normal growth and development.
Younger adolescents may have more difficulty adhering to a strict daily medication regimen, which is crucial for the effectiveness of oral contraceptives.
They may be at a higher risk of certain side effects, such as irregular bleeding patterns and mood changes.
Acne treatment is often a primary reason for considering oral contraceptives in adolescents. However, alternative acne treatments that are more suitable for younger individuals are available.
Choice C rationale:
A hematocrit of 39 is within the normal range for females and does not contraindicate oral contraceptive use.
Hematocrit measures the proportion of red blood cells in the blood. Oral contraceptives can sometimes cause slight changes in hematocrit levels, but these changes are typically not clinically significant.
Choice D rationale:
A menstrual cycle of 14 days is considered a normal variation and does not pose a contraindication to oral contraceptives. Oral contraceptives can often regulate irregular menstrual cycles, so they may even be beneficial for individuals with shorter or longer cycles.
Correct Answer is []
Explanation
Condition
- A. Preeclampsia is the most likely condition the client is experiencing given the following:
- History of gestational diabetes and mild hypertension.
- Recent elevation in blood pressure.
- Preeclampsia is characterized by high blood pressure and can be associated with kidney involvement, as suggested by the increased blood pressure.
Actions
-
Administer prescribed antihypertensive medication: This is crucial for managing preeclampsia, as it helps lower blood pressure and prevent complications.
-
Monitor blood pressure and urine protein levels regularly: Essential for assessing the progression of preeclampsia and guiding treatment decisions. Monitoring helps track whether the condition is worsening or responding to treatment.
Parameters to Monitor
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Blood pressure readings: These are directly related to the severity of preeclampsia and help assess if the treatment is effective.
-
Level of protein in urine: Elevated protein levels indicate kidney involvement, which is a common complication of preeclampsia.
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